Background and Objectives: A descriptive exploratory study to assess the knowledge and skill of critical care nurses on endotracheal (ET) suctioning was conducted in the eight Intensive Care Units of AIMS, Kochi. The objectives of the study were (1) to assess the knowledge of critical care nurses on ET suctioning, (2) to assess the clinical skill of critical care nurses in performing ET suctioning, and (3) to find out the correlation between knowledge and clinical skill of critical care nurses on ET suctioning.Materials and Methods: The sampling technique used was nonprobability convenience (n = 50).Results: Majority of the participants (70%) had an acceptable level of knowledge. Most of the participants (64%) had least acceptable level of knowledge on the actual suction event and 54% on postsuctioning practice. The nurses who had an acceptable level of skill in performing ET suctioning were 56% whereas skill in practices before suctioning was least acceptable in 86% of the nurses. A significant difference (P < 0.001) was obtained between the current practice observed and the best recommended practice on ET suctioning. The elements of ET suctioning which were not followed by majority of the nurses include auscultation of chest (2%), postsuctioning assessment (2%), wearing apron (6%), maintaining suction pressure (10%), reassuring the patient before (30%) and after suctioning (18%), hand washing before (42%) and after suctioning (28%), time of suction applied (36%), and maintaining the suction catheter's sterility (46%).Interpretation and Conclusion: Even though nurses had an acceptable level of knowledge and skill, inadequacies exist in the practice of various phases of ET suctioning. Hence, training on ET suctioning could be focused specifically to those phases.

Mechanical ventilators are special pumps that can support the ventilatory function of the respiratory system and improve oxygenation through the application of high oxygen content gas and positive pressure. Another epidemiological study including 15,757 patients in the Intensive Care Units (ICUs) from twenty countries reported that 5183 patients (33%) required mechanical ventilation. [1],[2]

The primary objectives of mechanical ventilation are to decrease their work of breathing, relieve respiratory distress, rest the fatigued respiratory muscles, improve ventilation, stabilize the chest wall, and restore the acid-base balance. Therefore, the most common reasons for instituting mechanical ventilation are acute respiratory failure with hypoxemia (acute respiratory distress syndrome, heart failure with pulmonary edema, pneumonia, sepsis, and complications of surgery and trauma), which accounts for 65% of all ventilated cases, followed by the causes of hypercarbic ventilatory failure such as coma (15%), exacerbations of chronic obstructive pulmonary disease (13%), and neuromuscular diseases (5%). [2],[3]

Inappropriate and inaccurate ventilatory support strategy can result in increased mortality and complications. Pulmonary complications include barotrauma, oxygen toxicity, tracheal stenosis, and deconditioning of respiratory muscles. Even, mechanical ventilation for airway support can be a source of infection. Ventilator-associated pneumonia (VAP) can worsen gas exchange, increase the load of secretions, and can potentially lead to deterioration of the function of other body organs such as the heart. [2]

American nurses' association listed ten essential care to be provided for patients on mechanical ventilator, endotracheal (ET) suctioning is one among them. [4] The main goal of ET suctioning is to remove accumulated lung secretions to maintain the airway's permeability, provide adequate oxygenation, reduce the risk of VAP, and prevent pulmonary consolidation and atelectasis. As suctioning is a fundamental aspect of airway management, the critical care nurses must be competent in this essential clinical skill. Appropriate technique and adherence to evidence-based guidelines will result in fewer complications for the patients and ultimately, financial benefit to the patients by avoiding prolonged hospital stay.

Materials and Methods

Study design and population

A quantitative research with descriptive exploratory design was used to explore the knowledge and skill of critical care nurses on ET suctioning. The study was carried out among fifty critical care nurses working in eight ICUs of AIMS, Kochi.

Data collection

The data were collected using the following tools; Tool I: a structured questionnaire on knowledge regarding ET suctioning and Tool II: observation checklist on ET suctioning (standardized tool prepared by Mr. Seán J. Kelleher). Content validity of the tool was obtained from 12 experts in the field of nursing and medicine. The knowledge and skill scores were rated as highly acceptable (≤50% of score), acceptable (50-75% of score), and least acceptable (75% of score). The items on the both tools were classified into four phases; practices prior to suctioning, infection control practice, the suctioning event, and postsuctioning event.

Data collection for the study was conducted from December 7, 2014 to January 15, 2015. Ethical clearance was obtained from the Thesis Review Committee of AIMS, Kochi, after obtaining approval from the Research Committee of Amrita College of Nursing. Written permission was obtained from the nursing director, medical superintendent, and head of the department of each ICU. Nonparticipatory observation was conducted in the participants' natural environment using Tool II. ET suctioning practice was observed during morning and evening shifts in nursing care and in extubation contexts. An average of 3-4 observations were possible per day, but varied with the number of ventilator patients per day in the unit. The researcher prepared a list of participants observed, and written informed consent was obtained from the same participants after clearly explaining the purpose of the study. The Tool I was administered to the same participants at the end of their shift.

Data analysis

Karl Pearson's correlation coefficient was used to analyze the correlation between the knowledge and skill of critical care nurses on ET suctioning. One sample t-test was used to compare the observed practice score with the best recommended practice.

Results

Description of sample characteristics

The data shown in [Table 1] regarding the sample characteristics show that 64% of the participants were graduate nurses, 36% were general nursing and midwifery (GNM), and there was not a single postgraduate. Fifty-six percent of the nurses had 1-3 years of experience in the critical care unit and only 18% had more than 3 years of experience in the critical care unit.

Distribution of sample based on their knowledge level on endotracheal suctioning

[Figure 1] depicts that 70% of the participants had an acceptable level of knowledge, 8% of the nurses had highly acceptable level of knowledge, and 22% had least acceptable level of knowledge on ET suctioning.

Figure 1: Pie diagram on the distribution of sample based on the level of knowledge on endotracheal suctioning (n = 50)

[Figure 2] represents the four different phases of ET suctioning, of which majority of the participants (68%) had an acceptable level of knowledge on practices prior to suctioning and 50% on infection control practices. Most of the participants (64%) had least acceptable level of knowledge regarding the actual suction event and 54% on postsuctioning practice.

Figure 2: Bar diagram on the distribution of sample based on the level of knowledge on each phase of endotracheal suctioning (n = 50)

From [Table 2], it is clear that the maximum score of the knowledge questionnaire was thirty. The overall knowledge level of nurses on ET suctioning had a mean score of 17.28 (mean percentage of 57.6%) with standard deviation (SD) of ±3.580.

[Table 3] represents the four different phases of ET suctioning, of which majority of the participants (68%) had an acceptable level of knowledge on practices prior to suctioning and 50% on infection control practices. Most of the participants (64%) had least acceptable level of knowledge regarding the actual suction event and 54% on postsuctioning practice.

Table 3: Distribution of sample based on their level of knowledge on each phase of endotracheal suctioning (n=50)

Distribution of sample based on the skill level of critical care nurses on endotracheal suctioning

[Figure 3] describes that 56% of the participants had an acceptable level of skill, 44% had least acceptable level of skill, and none of them had highly acceptable level of skill in performing ET suctioning.

Figure 3: Pie diagram on the distribution of sample based on the level of skill in endotracheal suctioning (n = 50)

[Figure 4] depicts that among the four different phases of ET suctioning observed, 86% of the critical care nurses skill in the practices prior to suctioning was least acceptable, whereas in the rest of the three phases, their skill was acceptable; the actual suctioning event was 48%, infection control practice was 42%, and postsuctioning practice was 40%.

Figure 4: Bar diagram on the distribution of sample based on the level of skill in each phase of endotracheal suctioning (n = 50)

[Table 5] depicts that among the four different phases of ET suctioning observed, 86% of the critical care nurses skill in the practices prior to suctioning was least acceptable, whereas in the rest of the three phases, their skill was acceptable; the actual suctioning event was 48%, infection control practice was 42%, and postsuctioning practice was 40%.

Table 5: Distribution of sample based on their level of skill on each phase of endotracheal suctioning (n=50)

On analysing each step in detail, it was found that some of the steps in ET suctioning were ignored by more than 50% of the critical care nurses, which include auscultation of chest, postsuctioning assessment, wearing apron, maintaining suction pressure between 80 and 150 mm, reassuring the patient after suctioning, hand washing postsuctioning, explaining the procedure to the patient, length of time applied to suction the airway, hand washing prior to suctioning, and maintaining the suction catheter's sterility. Normal saline instillation was performed by 30% of the critical care nurses though it remains unsupported by scientific evidence (according to the American Association for Respiratory Care [AARC] Guideline, 2010).

The maximum score represents perfect adherence to best recommended practice, which was based on the scoring of standardized observation checklist by Kelleher and Andrews (Tool III). The higher a participants' observational score, the closer the participants' adherence to the best recommended practice. Similarly, the lower the participants' observational score, less likely was the adherence to best practice recommendation. From the [Table 6], it is clear that difference between the current practice observed in all phases of ET suctioning and best recommended practice was highly significant (P < 0.05).

Table 6: A comparison of current practice of critical care nurses on endotracheal suctioning observed with the best recommended practice (n=50)

There was no correlation (r = 0.077 and P = 0.596) between the knowledge and skill score of critical care nurses on ET suctioning.

Discussion

The findings of the present study consisted of 64% of graduate nurses, 36% of GNM, and there was not a single postgraduate. Eighty-two percent of the participants had 6 months to 3 years of experience in the ICU as the investigator considered a period of 6 months of working in ICU a sufficiently adequate time to acquire knowledge and skill related to ET suctioning. In a study conducted by Sharma et al. on the effectiveness of ET suctioning protocol in terms of knowledge and practices of nursing personnel (n = 30) in Mullana, it was found that 100% of the sample had professional qualification of GNM and 100% had within 5 years of experience in ICU. [5] In the present study, 78% of the participants did not attend training program on ET suctioning previously whereas in the study by Sharma et al., 56.67% had attended the in-service education related to ET suctioning. [5] A comparison with the above study findings shows that the present study findings can be more generalized to graduate nurses with <3 years of experience in ICU, mostly without a good background of training in ET suctioning.

It is encouraging to note from the present study that 70% of the participants had an acceptable level of knowledge on ET suctioning, though only 8% of the nurses had highly acceptable level of knowledge and 22% had least acceptable level of knowledge on ET suctioning. In a study by Ansari et al. (2012) on the gap between knowledge and practice in standard ET suctioning of ICU nurses (n = 44), 52.2% of the participants had desirable level of knowledge, 47.8% of the participants had moderate level knowledge, and none of them had undesirable level of knowledge on ET suctioning, [6] whereas in the present study, 22% of the participants had least acceptable level of knowledge. This may be because 100% of their participants were graduate nurses and 63.5% of the participants' experience was more than 4 years. [6]

In the present study, the knowledge level of nurses was analyzed separately under four phases, and acceptable level of knowledge was found in two phases, i.e., practices prior to suctioning (68%) and infection control practices (50%); least acceptable level of knowledge was found in two phases, i.e., actual suction event (64%) and postsuctioning practice (54%). However, the mean percentage of knowledge score in three phases was acceptable at 59%, 76%, and 52.3%, respectively, except for postsuctioning practice (41.3%). The present study findings differ from the study by Ansari et al., where the mean percentage of knowledge score obtained before suctioning, during suctioning, and postsuctioning was 71.25%, 77%, and 80.8%, respectively. [6]

Even though nurses' overall knowledge score was acceptable, while assessing in depth, it was found that deficiency exists in some phases of ET suctioning, i.e., the actual suctioning event and postsuctioning practice. Hence, educational interventions on ET suctioning need to be focused more on these phases.

The present study revealed that 56% of the participants had an acceptable level of skill, 44% had least acceptable level of skill, and none of them had highly acceptable level of skill in performing ET suctioning. The findings also indicate that the mean percentage of overall knowledge score (57.6%) of critical care nurses on ET suctioning was better than their practice score (51.9%). In this context, there are two studies from literature that indicate that nurses have more knowledge than practice. In the study by Ansari et al., the mean knowledge and practice score obtained was 19.59 and 8.75, respectively, out of the maximum 26 possible score. The findings of this study showed that 95.4% of the participants' practice score was undesirable (<50%), 4.6% of the participants' score was moderate (51-75%), and none of them had desirable level of practice (>75%). [6] Another study by Day et al. (2002) on tracheal suctioning, an exploration of nurses' knowledge and competence in acute and high dependency ward area, London (n = 28), was in tune with this finding, where the average score obtained for knowledge and performance was 11.2 and 10.3, respectively, out of 20 maximum score. [7] In contrast, in another study by Sharma et al., practice was better than knowledge. The mean percentage of pretest score of knowledge and practice obtained in the study was 42% and 38%, respectively. This may be related to the sample characteristics of the study, where 100% of the participants were GNM and 56.67% of the participants did not receive in-service education on ET suctioning previously. [5]

Like the assessment of knowledge of nurses, the practice score was also assessed under four phases. Among which the nurses had an acceptable level of practice in three phases, i.e., the actual suctioning event (48%), infection control practice (42%), and postsuctioning practice (40%), with the mean percentage of 56.7%, 62%, and 48.4%, respectively, and the nurses had least acceptable level in practice prior to suctioning (86%) with the mean percentage of 39%. The present study findings differ from the study by Ansari et al., where the mean percentage of practice score obtained before suctioning, during suctioning, and postsuctioning was 27%, 72.66%, and 68.1%, respectively. [6] An important point to be considered here is that in both studies, the knowledge score of the participants on the phase prior to suctioning was much higher than their practice score in the same phase.

Even though an acceptable level of skill was shown by 56% of the critical care nurses, the finding of this study has brought light to a few inadequacies in ET suctioning practice observed.

The present study findings showed that 98% of the nurses literally failed to auscultate the chest of the patients prior to suctioning as well as postsuctioning. Best practice recommendations on ET suctioning suggest that when performing a respiratory assessment, nurses should auscultate the patient's chest to verify the need for ET suctioning. [8] Most of the studies support this finding. An observational correlational study by Jansson et al. on the evaluation of ET suctioning practices conducted in ICUs (n = 40) also reported that only 5.3% of the nurses performed chest auscultation before suctioning and 0% postsuctioning. [9] Given that the majority of the participants failed to auscultate lung sounds before ET suctioning, it might be possible that they were working from a combination of clinical signs that indicated the necessity for ET suctioning, such as noisy breathing or visible secretions in the airway. A limitation of observational methods, however, meant that there was no way of establishing whether participants' decision to perform ET suctioning was informed by such indicators or whether they were working from some other perspectives such as unit routine as is suggested in the literature. [8] Failure in auscultation before and after suctioning in the present study and above-mentioned studies most probably indicates that nurses continue to practice based on mostly symptoms and not signs. This also indicates the necessity of including physical examination mandatorily in nursing practice.

Evidence from the present study revealed that only 30% of the participants explained the procedure to the patient before suctioning and 18% reassured patient after suctioning. However, this was contradictory to the findings of a study by Jansson et al., where 61.5% of the participants explained the procedure to the patient before suctioning and 62.5% reassured the patient after suctioning. [9] A similar picture was found in the study by Kelleher and Andrews which was an observational study on the open-system ET suctioning practices of critical care nurses, Ireland (n = 45), where only 28% of the participants in general ICU (GICU) failed to communicate in any form. [8] However, these contradictory results are an eye opener that indicates good communication is possible inside an ICU despite the condition of the patient.

Despite the abundance of evidence on the negative consequences of suctioning-induced hypoxemia, in the present study, only 54% of the participants performed presuctioning hyperoxygenation, though it is worth noting that 74% of the participants performed hyperoxygenation postsuctioning. Field notes by the researcher identified that the nurses used Ambu or ventilator for hyperoxygenation/hyperinflation, but the technique varies among ICUs. A similar picture could be seen in the study by Kelleher and Andrews, where 17 out of 45 participants failed to provide hyperoxygenation/hyperinflation either before or after ET suctioning. [8] The routine practice may have been learned from each other without ever actually understanding the rationale for its use. This also shows that practices among nurses might be routine, symptom-oriented, and not proactive.

Another area of concern was normal saline instillation which was practiced by 30% of the participants in the present study. This was reflected in the study by Jansson et al., where 25% of the participants performed normal saline instillation. [9] Similar findings were seen in earlier work in the ICU setting too, with 100% (n = 16) of nurses believing that saline should be used to loosen secretions. What is even more worrying is that most of these nurses (n = 11, 69%) were aware of the complications of saline. Bostick and Wendelglass (1987) argued that this is an example of a widely practiced intervention that is not supported by research. In fact, there is considerable research evidence against its use (Blackwood 1999). AARC also does not recommend using normal saline instillation as a routine practice while performing ET suctioning. Hence, this a controversial issue which further requires scientific evidence. French (1999) argued that despite an increasing body of knowledge about the effectiveness of interventions, there remains a discrepancy between theoretical knowledge and practical application. This argument certainly seems to apply. [10]

It was found in the present study that only 6% of the participants wore apron, only 42% of the participants washed hands before suctioning, and 28% postsuctioning. It is appreciable to note that 100% of the participants wore glove and 88% wore face mask during suctioning. A similar finding could be seen in the study by Kelleher and Andrews where hand washing was poorly performed (GICU: 31% and CICU: 65%) and only a few wore goggles (CICU: 12%, GICU: 3%) during the ET suctioning procedure. However, all the participants had worn gloves, face mask, and apron. [9] It is recommended strongly in many literature that hands should be washed before and after suctioning and that aprons, gloves, and goggles should be worn during suctioning to reduce the risk of infection before suctioning as well as prevent cross infection after suctioning. [9] This was contradictory to the findings of the study by Jansson et al., where hand washing was performed by 72.2% of the participants before suctioning and 52.5% postsuctioning. One hundred percent of the participants wore gloves, 97.5% wore face mask, 32.5% wore apron, and 25% protected their eyes from infection. [9]

These findings may suggest a perception among nurses that wearing gloves and using a "non-touch" aseptic technique when inserting the suction catheter negate the need for frequent hand washing, yet the literature clearly suggests that gloves do not replace the need for handwashing (Pratt etal. 2001). Protective eyewear is especially important, as the eye itself and surrounding delicate mucous' membranes are very vascular. Any splashes of infective sputum could pose a serious infection control threat to the practitioner who is performing the procedure. [8] The practice of wearing apron and goggle is an uncommon practice in many hospitals around the country; this might be the reason that only 6% of the participants in the present study had worn apron and that none of them wore goggle.

Above all, sterility of the suction catheter until inserted into the airway was maintained only by 46% of the participants in the present study. Even, Kelleher and Andrews have mentioned in their study that 10 (59%) CICU and 8 (29%) GICU participants failed to maintain the sterility of the suction catheter before its insertion into the patient's airway. [8]

The field notes maintained by the researcher identified that most often, catheter touches the patient linen and nonsterile glove touches the catheter and small opening tip of normal saline bottle, through which nurses try to squeeze in the catheter for cleaning. The equipment listed by AARC guideline on ET suctioning has clearly stated that sterile water and cup and sterile glove have to be used for open ET suctioning technique. [11]

In the present study, 64% of the participants failed to apply suction to airway for < 15 s. The recommended practice suggests that suctioning should take between 10 and 15 s to perform, as longer durations are associated with an increased risk of hypoxemia and trauma (Boggs 1993). [10]

Another area of particular concern was that only 10% of the participants maintained a suction pressure between 80 and 150 mmHg while performing ET suctioning. The field notes by the researcher identified that participants maintained a suction pressure between 250 and 450 mmHg, which was much higher than the recommended pressure. High negative pressure will cause mucosal trauma, which, in turn, predisposes the bronchial tree to a higher risk of infection. Using high negative pressures does not mean that more secretions will be aspirated, therefore limiting pressures to between 80 and 150 mmHg is recommended. [8]

Results from the study by Kelleher and Andrews indicated that all participants used suction pressures outside the recommended levels for safe practice with suction pressures ranging from 230 to 450 mmHg. Participants from GICU generally utilized lower suctioning pressures, ranging from 230 to 380 mmHg, but again these still exceeded the recommended pressures for safe practice. [8] Another study by Jansson et al. also supported the same finding where only 15% of the participants maintained a suction pressure between 80 and 150 mmHg. [9]

The above findings indicate that there are many concerns regarding the adherence of critical care nurses on ET suctioning. This was confirmed when a comparison was made between observed practice and the best recommended practice on ET suctioning. A significant difference (P < 0.01) was obtained between current practice and best recommended practice. These findings were in line with the inference of two studies; by Kelleher and Andrews (2008) [8] and by Jansson et al., [9] where it was found that in all categories, there was significant difference (P < 0.001) between the quality of treatment observed and quality of treatment required in ET suctioning.

The above-discussed studies indicate that there is a gap between the knowledge and skill of critical care nurses. However, a number of studies have demonstrated the gap between the theory and practice on ET suctioning. Larsen etal. (2002) believe that there is no gap between theory and practice using the sociological theory of Bourdieu, which challenged the "barrier paradigm" that has traditionally highlighted the gap between knowledge and practice. [10]

Conclusion

The study has shown deficit areas of knowledge and skill in specific phases of ET suctioning as well as a significant difference between the current practice observed and best recommended practice on ET suctioning. This may be because the nurses practice ET suctioning as learned from others or due to inadequate training during student/staff period. The need for skill training program specific to practice areas of nursing before independent patient care assignment in critical care unit has become evident through the present study.

Acknowledgment

I thank Mr. Seán J. Kelleher for permitting me to use the observation checklist. Moreover, I would like to thank every person who supported and encouraged me to complete the research study successfully.